In the emotional roller coaster of life, sometimes the down periods have long-lasting effects on more than just your mood. In fact, numerous studies link factors that impact your emotional well-being—such as stress, depression and anxiety—to an increase in skin, hair or nail problems. Now, dermatologists are advising patients to recognize these secondary symptoms and to seek treatment early before they cause additional stress.

Speaking at the American Academy of Dermatology’s Skin Academy, dermatologist and clinical psychologist Richard G. Fried, MD, PhD, FAAD, of Yardley, Pennsylvania, discussed the reciprocal relationship between feelings and appearance, and how failing to address these concerns can affect how you look, feel and function. “When patients are going through a rough period in their lives, negative emotions can wreak havoc on their appearance,” said Fried. “So, as a result, patients might start to notice that their hair is thinning, their skin is inflamed or their nails are brittle, which can be physical manifestations of their mental state. These unwanted physical changes can have a profoundly negative impact on how they feel. The negative emotions can trigger a vicious cycle of worsening skin, hair and nails leading to worsening of their emotional state and can lead to further worsening of the skin problem. Dermatologists can play a key role in helping patients not only alleviate these physical symptoms, but also help enhance their quality of life during a difficult time.”

Psychodermatology interventions

Stress can manifest itself in one’s appearance in many ways, primarily by making the skin more sensitive and more reactive. For example, Fried noted that stress can make rosacea more red, result in acne lesions that are more inflamed and more persistent, cause brittle nails and ridging of the nails, cause hair loss, cause or worsen hives, and cause excessive perspiration.

In addition, stress also is a known trigger or can be a worsening factor for fever blisters, psoriasis, seborrheic dermatitis and has even been shown to impair skin barrier function and dehydrate the skin, allowing more irritants, allergens, and infectious agents to penetrate the skin and cause problems. Stressed skin often appears stressed, distressed and older.

“When it comes to treating patients who we suspect may be experiencing skin, hair or nail problems as a result of stress or other emotional factors, it is helpful to ask them whether their skin seems to look or feel worse when they are stressed,” said Fried. “Beyond the direct physiological effects of stress, patients under stress also tend to neglect or abuse their skin, lacking the energy and motivation to adhere to their skin care regimens. There also might be signs of stress-related behaviors—such as scratching, pulling or rubbing—that can exacerbate problems.”

To successfully treat stress-related dermatologic conditions, Fried recommends that traditional dermatologic therapies should be used in conjunction with appropriate stress management strategies. For example, Fried discussed how stress reduction interventions and techniques can reduce the culmination of negative events that can worsen many of these problems.

To illustrate the seriousness of living with skin problems, Fried points to studies showing that people tend to be more distressed by skin, hair or nail problems since they are so visible and uncomfortable, than by other serious medical conditions, such as heart disease or diabetes.

"When dermatologists treat both the skin and stress, the skin often clears more quickly and completely as the native influences of stress are diminished,” said Fried. “Consequently, their overall anxiety level can decrease and they may start to feel better about how they look and how they’re feeling emotionally.”

Moving to the microscopic level, Fried added that stress reduction can decrease the release of pro-inflammatory stress hormones and chemicals. For example, release of neuropeptides—stress chemicals released from the nerve endings—can be reduced with stress management techniques. This often results in skin that looks and functions better. These interventions can reduce blood vessel over-activity, resulting in less blushing or flushing. Decreasing stress allows the patient to focus more positive energy on good skin care rather than negative behaviors.

“It is fair to say that when people are under stress, they tend to ‘fall off the wagon’ in terms of practicing good skin care,” said Fried. “They may not use their sunscreen or their skin care products when they’re feeling stressed, because all of their energy and focus is being diverted by their ongoing stress. They also might not be eating or sleeping as well or staying hydrated, which all can contribute to a dull or lackluster appearance.”

With accurate diagnoses by a dermatologist, effective treatments improve the appearance and function of the skin. This alone can substantially reduce patients’ stress and improve their skin, hair and nail conditions. However, Fried noted that if stress is clearly interfering with patients’ overall well-being and ability to cope, simultaneous stress management interventions are warranted. In some instances, referral to a mental health professional who has an interest and understanding of skin problems may be warranted.

Cosmetic interventions

While skin rejuvenation procedures have been shown to significantly improve a person’s outward appearance, studies suggest these types of cosmetic interventions also can have positive effects on how people feel and how they function.

“When people feel more attractive and more confident in their appearance, they tend to perform better in other areas of their lives—in their work, family life, social life, and marriage or personal relationships,” explained Fried. “Under the right circumstances, cosmetic procedures can be a powerful ally. But it’s important for patients to understand that these procedures are not a panacea. Realistic expectations are the key to effectively delivered promises.”

Currently, Fried is analyzing data from a 2008 study designed to measure the positive ripple effects of botulinum toxin injections on other aspects of patients’ lives. In this study, 76 middle-aged patients were treated with one botulinum toxin injection and then asked to complete a questionnaire during their follow-up visit to gauge how they felt following the procedure.

“The results of our study clearly showed that patients treated with botulinum toxin experienced substantial benefits,” said Fried. “In fact, 29% reported feeling less anxious, 36% said they feel more relaxed, and 49% were more optimistic. Even a portion of patients diagnosed with seasonal affective disorder, or SAD, prior to treatment reported they felt less sadness during the winter following botulinum toxin injection.”

A previous study conducted by Fried evaluated the clinical and psychological effects of the use of alpha hydroxy acids (AHAs) in 32 patients. After 12 weeks, patients demonstrated significant improvements in facial skin tone and fine wrinkling, and reported satisfaction with their physical appearance and the quality of their interpersonal relationships.

“The results of these two studies echo observations of recognized experts from around the world—that cosmetic interventions can improve a patient’s self-image and help them feel better about themselves,” added Fried. “Feeling stressed, depressed or anxious is exhausting, and patients who report improvements in these negative feelings following a cosmetic procedure can use that redirected energy to pursue new interests that can enhance their lives.”

For proper diagnosis and treatment of any skin, hair or nail conditions, Fried advised patients to consult their dermatologist s to determine the root of the problem and discuss the potential benefits of any treatment.